gms | German Medical Science

Objective: To evaluate the long-term radioanatomical and clinical results in patients with complex/giant middle cerebral artery (MCA) aneurysms treated by endovascular surgery supplemented by cerebral bypass techniques.

Method: Twenty-five patients harbored MCA - aneurysms with complex anatomy (intraaneurysmal thrombus/ calcification, fusiform shape, incorporated branches), of whom nine presented with ruptured lesions and the others with mass effect or neurological dysfunction.

Results: Nine aneurysms were coil-occluded only with stable > 90 % -100 % long-term occlusion rates in 5 of them available for follow-up. Fourteen out of 17 were successfully obliterated by mostly MCA endovascular parent artery occlusion (PAO) combined with extra-intracranial bypass surgery. One of them showed repeated bypass occlusions due to coagulopathy and later received a stable stent/coil construct. Another demonstrated insufficient bypass flow to accept PAO. One patient was revascularized after stent induced progressive MCA- stenosis. Seventeen patients enjoyed a favorable clinical result (mRS 0-2). Two remained in fair condition due to the impact of the initial hemorrhage or preoperative stroke. Four patients died later, 3 of them due to unrelated causes (cancer in 2, MI in 1) and 1 of unknown cause. Two complications related to the applied technique occurred (1 perforator occlusion after PAO and 1 rebleeding after palliative coiling a poor grade patient leading to a final mRS 3 outcome score in both.

Conclusions: Satisfying outcomes can be achieved by integrating endovascular surgery or combining both modalities in the treatment plan in these otherwise difficult to treat lesions. Neck remnants after selective coiling should be monitored closely and treated if exhibiting a progressive behavior.